Traditional Complementary and Alternative Medicine(TCAM) Use Among PLHIV on Antiretroviral Medication.

doi:10.21203/rs.3.rs-3098652/v1

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Traditional Complementary and Alternative Medicine(TCAM) Use Among PLHIV on Antiretroviral Medication.

https://doi.org/10.21203/rs.3.rs-3098652/v1

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Background: Traditional complementary and alternative medicine (TCAM) are products and practices that differ from conventional allopathic medicine. There continues to be an increase in the use of these methods of treatment in developed and developing countries worldwide. This often owes to the perceived ability of these treatment methods to cure chronic medical conditions like HIV. However, TCAM use may be associated with reduced compliance with antiretroviral medications, which leads to poor viral load suppression and increased risk for opportunistic infections. The concomitant use of antiretroviral drugs and TCAM practice may be influenced by some sociodemographic and health-related factors.

Objective: To determine the prevalence of TCAM use and examine the sociodemographic and health-related factors associated with its use among PLHIV on antiretroviral medications at the Infectious Disease unit of Korle-Bu Teaching Hospital in Ghana.

Methods: A cross-sectional study was conducted among attendants at an adult HIV clinic. 420 study participants were selected by systematic sampling. Data related to TCAM use, sociodemographic and health-related factors were collected using a standardized questionnaire and patient chart review. Multivariate logistic regression model was used to determine the association between TCAM use, sociodemographic and health-related factors.

Results: Majority of participants were female (76.2%) and had been diagnosed with HIV for ≥ 5 years (77.4%). The prevalence of TCAM use among PLHIV was 25.2%. No sociodemographic or health-related factor was significantly associated with TCAM use.

Conclusion: TCAM use was high among PLHIV. No sociodemographic or health-related factor was found to be associated with TCAM use. Further studies employing a qualitative approach using key informant interviews and focused group discussions are needed to explore reasons for its use. Care providers and policy-makers should look beyond sociodemographic and health-related factors in addressing TCAM use among PLHIV.

HIV/AIDS

Traditional

Alternative and Complementary Medicine

Persons Living with HIV (PLHIV)

Traditional, complementary and alternative medicine (TCAM) refers to products and practices that differ from conventional medicine. They consist of biological-based products like plant herbs, faith-based or spiritual/religious healing practices and mind-body healing techniques such as acupuncture, yoga, and massage [1, 2]. TCAM use is widespread globally, with an estimated prevalence between 76% and 80% in the general population [3, 4]. The use of this nonconventional method of medicine continues to grow, especially across the African continent leading to the establishment of research centers and the introduction of curricula in universities in countries such as Ghana, Nigeria, and South Africa for the purpose of studying these methods [1]. This is similar to the trend noted in Europe and other Western countries [5, 6]. In Ghana, the use of TCAM among the general population is estimated to be between 70% and 86%.[7][8].

The practice of TCAM use is particularly common among individuals with chronic medical conditions [9]. The advent of antiretroviral medications has significantly reduced morbidity and mortality associated with Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS), essentially rendering it a chronic medical condition [10].

The use of TCAM among persons living with HIV(PLHIV) is known to be relatively high, with a worldwide average prevalence of 50%-95% [11]. The average prevalence of TCAM use among persons living with HIV (PLHIV) in developed countries such as the USA stands at about 60% [12], and in developing countries like Ghana, about 53.2% [8]. The availability, affordability, and accessibility of TCAM, especially in developing countries, have contributed to their high level of acceptance [15].

Age, sex, marital status, educational background, rural or urban residence, and other sociodemographic factors have also been associated with TCAM use among PLHIV [16, 11, 9]. Some health-related factors have also been associated with its use. TCAM use is often associated with poor adherence to ART [10, 13]. Because the efficacy of antiretroviral treatment is dependent on strict adherence, TCAM use may be problematic among PLHIV. An adherence rate of at least 95% is needed to maintain optimum viral load suppression and other positive treatment outcomes [14]. There has been concern about poor ART compliance with subsequent adverse outcomes and drug resistance among PLHIV in communities with high levels of TCAM use.

In this study, we examined the level of TCAM use among attendants of an HIV clinic in Ghana and explored the association between TCAM use and sociodemographic and health-related factors.

2.1. Study design and data collection

This was a facility-based analytic cross-sectional study among attendants of the adult HIV clinic at Korle Bu Teaching Hospital between June and August 2020. The study was limited to PLHIV aged 18 years and above who had been on antiretroviral treatment for at least 6 months. A standardized questionnaire was used for data collection on TCAM use, sociodemographic and health factors associated with its use among PLHIV that access care at the unit. In addition, participant health information such as duration of diagnosis, duration on antiretrovirals, HIV-typing, ART regimen, and viral load within the past year was extracted from health records and documented in the questionnaire.

Self-adherence to medications was ascertained for all participants. The study protocol (KBTH-IRB/00047/2020) was reviewed and approved by the Korle Bu Teaching Hospital Institutional Review Board on 27th May 2020.

2.2. Dependent and Explanatory Variables

The dependent variable of interest was TCAM use. This was assessed in the survey by the response to the question, "Do you currently use traditional or alternative forms of medicines aside from the ones that your doctor prescribed?"

Sociodemographic factors

Data were collected on sociodemographic factors such as age, education, sex, religion, marital status, occupation, and region of residence using a standardized questionnaire. The region of residence was categorized into: "Rural," "Peri-urban," and "Urban."

Health-related factors

Health-related factors examined in this study were HIV type, HIV viral load, duration of HIV diagnosis, duration of ART treatment, ART regimen, ART adherence rate, and comorbidities. These were obtained from patients using the questionnaire and review of patient health records.

ART adherence rate was assessed by a standardized 30-day recall of medications using the Brief adherence rating scale (BARS) and pill count. The low-cost, ease of administration, and minimal patient burden it offered made it favorable to carry out the study in an outpatient clinic [17].

2.3. Statistical Analyses

Descriptive statistics were first produced for each variable. Following this, Chi-squared tests were performed to examine the differences in the independent variables between the two TCAM use categories. Multiple logistic regression was then utilized to examine the association between TCAM use and the predictor sociodemographic and health-related variables. All analyses were done with STATA (version 16). Statistical tests were 2-sided, and the significance level was set at 0.05.

3.1. Sociodemographic Characteristics of the Study Population

Table 1 summarizes the sociodemographic characteristics of respondents. 76.2% of respondents were female, and 82.1% were above 40 years old. The prevalence of TCAM use among study participants was 25.2%.

Table 1

Sociodemographic characteristics of study participants
Sociodemographic Factors (N = 420)	n (%)
Gender
Male	100 (23.8%)
Female	320 (76.2%)
Age Category
< 40 years	75(17.9%)
\(\ge\)40 years	345(82.1%)
Education
Primary	151 (35.9%)
Secondary	141 (33.6%)
Vocational/Technical	31 (7.4%)
Tertiary	32 (7.6%)
None	65 (15.5%)
Residence
Rural	11 (2.6%)
Urban	327 (77.9%)
Peri-urban	82(19.5%)
Employment Status
Formally employed	49 (11.7%)
Informally employed	323(76.9%)
Unemployed*	38(9.0%)
Retired	10(2.4%)
TCAM use
Yes	106(25.2%)
No	314(74.8%)
*Includes students

3.2 Sociodemographic factors and TCAM use

Table 2 summarizes the chi-square analysis results to examine the differences in sociodemographic factors between the two TCAM use categories. There was no significant difference in sociodemographic factors between respondents who used TCAM and those who did not.

Table 2

Chi-square analysis of sociodemographic factors by TCAM use category
Variables	TCAM use Yes No (N = 106) (N = 314)		p-value (χ² )
Sex			0.466
Male	28(26.4%)	72(22.9%)
Female	78(73.6%)	242(77.1%)
Age Category			0.525
< 40 years	17(16%)	58(18.5%)
\(\ge\)40 years	89(84%)	256(81.5%)
Religion			0.215
Christian	91(85.8%)	280(89.2%)
Muslim	14(13.2%)	26(8.3%)
Other	1(1%)	8(2.5%)	`
Marital Status			0.585
Single	23(21.7%)	70(22.2%)
Married	41(38.7%)	131(41.7%)
Widow/Widower	21(19.8%)	55(17.5%)
Separated	3(2.8%)	18(5.7%)
Divorced	8(7.5%)	23(7.3%)
Cohabiting	10(9.5%)	17(5.6%)
Residence			0.885
Rural	3(2.8%)	8(2.5%)
Peri-urban	19(17.9%)	63(20.1%)
Urban	84(79.3%)	243(77.4%)
Education level			0.856
None	15(14.2%)	50(15.9%)
Primary	38(35.8%)	113(36%)
Secondary	38(35.8%)	103(32.8%)
Vocational/Technical	9(8.5%)	22(7%)
Tertiary	6(5.7%)	26(8.3%)
Employment Status			0.881
Unemployed	9(8.5%)	29(9.2%)
Formally employed	10(9.4%)	39(12.4%)
Informally employed	84(79.2%)	239(76.1%)
Retired	3(2.9%)	7(2.3%)

3.3 Health-related factors and TCAM use

Table 3 summarizes the results of the chi-square analysis to examine the differences in health-related factors between the two TCAM use categories. Again, there was no significant difference between the two TCAM use categories.

Table 3

Chi-square analysis of health-related factors by TCAM use category
Variables	TCAM use Yes No (N = 106) (N = 314)		p-value (χ² )
HIV type			0.985
Type 1	103(97.2%)	305(97.1%)
Type 2**	3(2.8%)	9(2.9%)
Duration of HIV diagnosis			0.769
< 5 years	25(23.6%)	70(22.2%)
5–10 years	40(37.7%)	110(35%)
> 10 years	41(38.7%)	134(42.8%)
Duration on ART			0.906
< 5 years	25(23.6%)	70(22.2%)
5–10 years	38(35.8%)	109(34.7%)
> 10 years	43(40.6%)	135(43.1%)
HIV viral load			0.154
\(\le\)1000cp/ml	97(91.5%)	299(95.2%)
> 1000cp/ml	9(8.5%)	15(4.8%)
Comorbidity			0.653
Yes	26(24.5%)	84(26.8%)
No	80(75.5%)	230(73.2%)
ART adherence rate			0.355
\(\le\)95%	29(27.4%)	101(32.2%)
> 95%	77(72.6%)	213(67.8%)
ART Regimen			0.886
NNRTI-based	83(78.3%)	238(75.8%)
INSTI-based	17(16%)	57(18.2%)
PI-based	6(5.7%)	19(6%)
**includes respondents with both Type 1 and Type 2

3.4. Adjusted Multivariate logistic regression for the association between TCAM use and sociodemographic, health-related factors.

The results of the logistic regression are summarized in Table 4. No sociodemographic and health-related factor was found to be significantly associated with TCAM use.

Table 4

Multivariate Logistic Regression for the association between TCAM use and sociodemographic, health-related factors
Variable	aOR (95%CI)	SE	p-value
Sex Female Male	Ref 1.35(0.75,2.44)	0.41	0.322
Age Category < 40 years \(\ge\)40 years	Ref 1.42(0.72,2.81)	0.41	0.322
Religion Christian Muslim Others	Ref 1.84(0.86,3.90) 0.33(0.04,2.81)	0.71 0.36	0.114 0.309
Marital Status Married Single Widow/Widower Separated Divorced Cohabiting	Ref 1.30(0.69,2.45) 1.31(0.67,2.56) 0.62(0.17,2.26) 1.25(0.50,3.14) 2.49(0.98,6.32)	0.42 0.45 0.41 0.59 1.18	0.417 0.424 0.466 0.634 0.054
Residence Rural Peri-urban Urban	Ref 0.72(0.16,3.19) 0.72(0.18,2.98)	0.55 0.52	0.666 0.654
Education None Primary Secondary Vocational/Technical Tertiary	Ref 1.23(0.60,2.55) 1.48(0.71,3.09) 1.69(0.58,4.89) 1.17(0.31,4.48)	0.46 0.56 0.92 0.80	0.569 0.301 0.334 0.818
Occupation Formally employed Informally employed Unemployed Retired	Ref 1.50(0.56,4.01) 1.29(0.39,4.26) 1.82(0.36,9.15)	0.75 0.79 1.50	0.420 0.672 0.465
HIV Type Type 1 Type 2	Ref 0.78(0.16,3.90)	0.64	0.764
Duration of HIV diagnosis < 5 years 5–10 years > 10 years	Ref 5.69(0.40,79.99) 0.88(0.47,1.67)	7.67 0.29	0.198 0.704
Duration on ART < 5 years 5–10 years > 10 years	Ref 0.17(0.01,2.29) 1.00	0.22 -	0.180 -
HIV viral load \(\le\)1000 cp/ml > 1000 cp/ml	Ref 1.41(0.40,4.91)	0.90	0.595
Comorbid Condition No Yes	Ref 0.90(0.52,1.56)	0.25	0.711
ART adherence rate \(\le\)95% > 95%	Ref 1.26(0.75,2.12)	0.33	0.383
ART regimen NNRTI-based INSTI-based PI-based	Ref 0.82(0.43,1.57) 0.97(0.32,2.89)	0.27 0.54	0.551 0.952

The results of this study indicate that approximately one out of every four persons who seek HIV care at the Fevers unit uses some form of TCAM. Although significantly high, this rate is lower than that observed in a similar study conducted at Komfo Anokye Teaching Hospital in Ghana, which reported the use of TCAM in 50% of clinic attendants. [19]. It is also lower than the reported rates from similar studies from the Kwazu-Natal region of South Africa (51.3%) [19], Western Uganda (63.5%)[20], and Ethiopia(43.7%)[2]. Other literature in sub-Saharan Africa reported an average prevalence rate of about 45.8%[1]. However, the results were comparable to UK studies [4]. Most study respondents were from urban and peri-urban communities, where access to TCAM may be reduced, accounting for the relatively lower prevalence noted in our study. This prevalence, however remains considerably high, considering that all participants are HIV clinic attendants who have been on ARVs for at least 6 months, and have been previously counseled on ARV compliance and avoidance of TCAM use before starting ARV treatment.

Demographic factors have long been associated with TCAM use among PLHIV [1, 20, 21]. For example, the use of TCAM among PLHIV in some was previously reported to be associated with the female gender [1, 20]. Other studies have also shown an association between age and TCAM use among PLHIV [21]. The increased risk of comorbid conditions with age has been thought of as the main reason for this association [21]. However, neither gender nor age was found to be significantly associated with TCAM use in this study. Furthermore, other sociodemographic factors such as educational level, rural or urban settlement, and type of occupation were not found to be significantly associated with TCAM use in this study, although these were reported to be associated factors in a few studies in developed and developing countries [1].

Our results also show that comorbid disease conditions were not associated with TCAM use. This is a surprising finding as TCAM use was expected to be high among participants with chronic comorbid medical conditions seeking to cure or alleviate their symptoms with the use of TCAM. Hypertension was the most prevalent comorbid medical condition among study participants. The prevalence of hypertension in our study population was 21.2%, comparable to hypertension prevalence of 27% reported among PLHIV from studies in Nigeria and South Africa [22] and among the general population in Ghana of about 28%[23]. Although TCAM use among patients with hypertension in the general population is also well noted in other studies [24], a subgroup analysis of the comorbid disease conditions showed no association between hypertension and TCAM use in this study.

The use of TCAM in newly-diagnosed people with HIV was reported to be high, especially in the pre-ART era worldwide [25]. The impact of antiretroviral medications in improving treatment outcomes for PLHIV led to a gradual move away from the use of TCAM to treat HIV/AIDS. Some studies suggest that patients living with HIV for extended periods have higher odds of TCAM use due to the onset of comorbid medical conditions like diabetes and dyslipidemia [26]. The duration since diagnosis was therefore considered a predictor of TCAM use among PLHIV [25, 27]. In this study however, we found no association between duration since diagnosis and TCAM use. We note, however, that all our study participants have been diagnosed for durations greater than 6 months.

Optimum adherence to antiretroviral medications is objectively assessed by patient viral load. The results show no association between TCAM use and viral load. This suggests that the study participants who use TCAM are also highly adherent to ART treatment. The adherence rates calculated for the study participants confirm a high level of ART adherence. A high proportion of the study participants demonstrated an adherence rate of at least 95% and greater. There was no statistically significant association between the level of adherence and TCAM use. This showed that even though most patients adhered to ARV treatment, some still used TCAM. This highlights the fact that PLHIV are not using TCAM primarily to manage or cure HIV, but for other ailments. The high level of adherence at this HIV care clinic can be attributed to the level of health care staff and clinic health promotion and educative practices on adherence to ART. PLHIV who attend rural clinics were found to have a nine-fold likelihood of using alternative medicines compared to those that attended urban clinics like the Korle Bu Fevers unit [28]. The high compliance to ARV treatment and significant TCAM use among PLHIV further raises concerns of reduced drug efficacy and worse adverse effects in the event of any drug interactions between ARVs and TCAM.

This study was conducted among patients who are regular attendants of an HIV clinic in an urban teaching hospital with high levels of ART adherence. They are regularly seen and educated on avoidance of TCAM and strict ART adherence by various well-trained staff, including clinical psychologists, public health nurses, medical officers, and specialists in HIV. This may explain the lack of association between the sociodemographic factors and TCAM use seen in some previous studies. While these factors were not associated with TCAM use, there was still a high prevalence of TCAM use among study participants. There is a need to explore TCAM use further by healthcare providers and policymakers, especially with the ready availability of ARTs. New insights using a qualitative research approach are necessary to examine emerging factors that may drive TCAM use, especially among ART-compliant patients.

This was a single-site study with a cross-sectional design. A cause-effect relationship could therefore not be drawn for the association between TCAM use and the sociodemographic and health-related factors. In addition, a high proportion of participants had been diagnosed with HIV > 5 years and had high levels of adherence to ART treatment. Therefore, the results may not indicate the level of TCAM use among newly diagnosed, non-attendant, or non-compliant persons living with HIV.

The interviews conducted during clinic hours in the presence of healthcare providers may affect respondents' willingness to disclose TCAM use. There may have also been recall bias among study participants.

This study's findings indicated that there remains a continuing high level of TCAM use among PLHIV on antiretrovirals. However, with no sociodemographic or health-related factor found to be associated with TCAM use, further studies employing a qualitative approach using key informant interviews and focused group discussions are needed to explore reasons for its use. In addition, care providers and policy-makers should look beyond sociodemographic and health-related factors in addressing TCAM use among PLHIV.

TCAM- Traditional, Complementary and Alternate Medicine

PLHIV – Persons Living with HIV

AIDS -Acquired Immune Deficiency Syndrome

ARV -Anti Retroviral

Ethics Approval and Consent to participate

The Korle Bu Teaching Hospital Institutional Review Board (IRB) reviewed and approved the study protocol on 27th May,2020. (Protocol number KBTH-IRB /00047/2020). All study methods were carried out in accordance with relevant guidelines and regulations including the Declaration of Helsinki. Informed consent was obtained from all study subjects.

Consent for publication: N/A

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Competing Interest

The authors declare that they have no competing interests.

Funding

The authors received no funding for this study.

Authors Contributions

MKID – drafting of article, data analysis, review and revisions, final approval; MAEB - review and revisions, final approval; FA – review and revisions, final approval; CAN – review and revisions, final approval; KPB – conception and design, drafting of article, review and revisions, final approval

Acknowledgments

The authors want to acknowledge all workers at the Infectious Disease Unit at KBTH for their help during the study, and the participant patients who agreed to be part of the study.

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No competing interests reported.

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Traditional Complementary and Alternative Medicine(TCAM) Use Among PLHIV on Antiretroviral Medication.

Traditional Complementary and Alternative Medicine(TCAM) Use Among PLHIV on Antiretroviral Medication.

Status:

Version 1

Abstract

1 BACKGROUND

2 MATERIALS AND METHODS

2.1. Study design and data collection

2.2. Dependent and Explanatory Variables

2.3. Statistical Analyses

3 RESULTS

3.1. Sociodemographic Characteristics of the Study Population

3.2 Sociodemographic factors and TCAM use

3.3 Health-related factors and TCAM use

3.4. Adjusted Multivariate logistic regression for the association between TCAM use and sociodemographic, health-related factors.

4 DISCUSSION

5 LIMITATIONS

6 CONCLUSION

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1